135

QUERY DRUNK?

THE LANCET.

LONDON: SATURDAY, JANUARY 17, 1925.

QUERY DRUNK?

AMONG the physical conditions investigated in courtsof law, where medical evidence is of essential import-ance in determining the issues involved, two-namely,insanity and drunkenness-have a common featurewhich distinguishes them from other variations ofnormal health. To borrow a phrase from Sir JAMESPURVES-STEWART’S lucid and valuable address on

Acute Drunkenness, delivered before the Society forthe Study of Inebriety on Tuesday last and publishedin THE LANCET this week, neither is " a simple clinicalentity like a broken bone or a consolidated lung," asto which medical evidence must almost necessarilybe accepted in favour of one side or the other. And asto the existence of insanity or of drunkenness-andthey may occur in combination-lay witnesses havetheir say in most cases involving legal question, andgive evidence upon which members of a lay tribunal,magistrates, jurors, or judges, consider themselves

fully entitled to form independent and conclusive

opinions in the light of their general experience of life.This introduces a difficulty of which medical witnessesshould be fully aware, and which at times leads toconclusions which medicine cannot accept as satis-

factory. Sir J. PURVES-STEWART’S address should beread in conjunction with Dr. R. T. WILLIAMSON’Spaper on Mortality from Motor Traffic, which wepublish also this week, when it will be realised, perhapsmore fully than before, that the huge increase ofmotor-drawn vehicles which has taken place in recentyears, and which shows every promise of continuing,has added fresh importance to the diagnosis ofdrunkenness, while introducing variations of the natureof the evidence required with regard to it. The manarrested a few years ago for being drunk when incharge of a vehicle had to meet an accusation in muchless serious circumstances when his wheels were drawn

by a horse, upon whose " horse-sense " he, and the

public, to some extent relied ; the man who now is

brought before the court for drunkenness when drivinga motor-car or lorry is more than occasionally requiredto stand a charge of manslaughter. It becomes nowa charge of manslaughter if anyone has been killed

through the alleged intoxication of a driver ; it is

potential manslaughter, visualised by the tribunal, ifan arrest by the police is believed to have averted theoffence of an intoxicated driver.

It is to be noted that the medical aspects and prac-tical tests of acute drunkenness, as considered by SirJ. PURVES-STEWART, appear to divide the cases ofdrunkenness, presenting themselves for diagnosisthrough action of the police, into two main classes.In the one class the man charged may be the victimof physical conditions of which the police who arrestedhim were naturally unaware, conditions of which thesymptoms are similar to those of intoxication byalcohol, but which, in fact, are due to entirely differentcauses. An extraordinarily apposite illustration ofthis sort of case is given by Sir J. PURVES-STEWART,furnished by a medical colleague. Here the driver ofa car was suffering from chronic Eustachian catarrhand frequent labyrinthine vertigo. Having drunk aglass of gin and vermouth, which imparted to hisbreath the odour suggestive of alcoholic intoxication,he allowed the car which he was driving to mount the

footpath and come into contact with a foot passenger,having been compelled to avoid another foot passengerat a street corner. Conviction was followed by animmediate appeal and a rectification of the mis-

carriage of justice ; and in this case there were fullopportunity and means for setting right the excusableerror into which the police had fallen. This will usuallyoccur where the accused has a physical excuse

to account for an accident. Analysis of the cerebro-spinal fluid, which Sir J. PURVES-STEWART finds theonly, or at any rate the most convincing, wayof proving the presence and absence of alcoholicintoxication is a drastic proceeding which can neverbecome a popular test. Non-medical evidence forthe elimination of alcohol as the cause of thesymptoms observed will naturally be called to supple-ment scientific testimony, but such evidence isnot always at the command of the man or womanbrought before the magistrate as drunk and disorderlyor incapable. In these cases reliance must be placedupon the experience of the police surgeon, who fullyrealises that the easy course of confirming the policeview has often led to injustice. Where the accused canproduce any evidence that what have seemed to thepolice to be the manifestations of intoxication are theresults of physical default, we may be certain to-daythat careful note will be taken of such a defence,which will be complete if the misleading symptomspersist after the period of alcoholism should have

gone by.The second class of case where careful consideration

of the tests for drunkenness is required, and whereincreasing use of motor vehicles has multiplied theexamples, is the accident occurring when the driveris not fully alert. A motor-driver has, to use Dr.WiLLiAMSON’S phrase, " a terrible weapon to control,"and the danger in which he may place his fellow citizensat any time may be less apparent than it should beto his mind if he has consumed alcohol in far smallerquantities than would bring him under the notice ofthe police as a pedestrian or as the driver of a horse.The driver we are now considering is in normal healthand not able to assign the symptoms observed in himto any previously existing condition not caused byalcohol. He is not so intoxicated, we may here alsosuppose, as to be helpless, disorderly, or quarrel-some. Nevertheless, his conduct as a motor-drivermay call for the notice of the police. The customarystory of such a case is that the driver vehementlydisputes the justice of his arrest, and denies thatalcohol has anything to do with the alleged irregularityin his conduct as a driver. He is brought to the policestation, and having been seen by the inspector incharge, a police surgeon examines him, and perhapssome other doctor, possibly his usual medical attendant.In the meanwhile his condition in respect of drunken-ness may have changed considerably. He may havegrown worse than when he was arrested, or he mayhave shaken off to a great extent the supposed effectsof what he has imbibed. He may have been excitedand have become worse, or he may have grown calmer.In any case, the medical man who examines him is not

likely to find him as he was when first taken into

custody, and his condition is not that of a man whohas been recently helpless from drink. In thesecircumstances the foundation of a definite opinion by amedical practitioner may be difficult, and its enuncia-tion is not rendered easier by the attitude of somemagistrates, who dislike explanatory phrases, andexpect a witness to answer

" Yes " or " No " to thequestion " Was the prisoner drunk ? " while neithermagistrate nor doctor is agreed upon any definitionof drunkenness.

136 THE PANEL PRACTITIONER’S RIGHT OF APPEAL.

Sir J. PuRVES-STEWART makes it plain that it isdifficult to supply a definition of drunkenness satis-factory to medical men and at the same time con-venient of application before a lay tribunal. Moreover,drunkenness which a magistrate would rightly condemnin the case of the driver of a car or lorry, differs fromthat which is brought to his notice in other connexions.On the whole, in view of the difficulty of defining andproving, or disproving, drunkenness in its medico-legalaspects, it is well that we can accept the estimatethat in nine cases out of ten the policeman’s diagnosis is correct-we might even fix the proportion of Iright decisions by the constable at a higher figure. IThe matter deserves serious consideration when wefind how steadily and how rapidly the number offatal accidents due to motor vehicles has increasedand is increasing. Mistakes may be made and it

may, at times, be the function and the privilege ofthe medical witness to prevent or to correct them bycareful diagnosis. At others it will be his duty to Isee that men who drink intoxicants when they knowthat they have to drive should have their condition

fully explained to the authorities responsible for thepublic safety. Dr. WILLIAMSON suggests that motor-car drivers should be fined for every fatal accident.We do not endorse this as a practical remedy, noris it, we think, consistent with the generally acceptedview of justice. We are more in accord with his

opinion that all drivers should abstain from alcohol

during their hours of duty, and should be requiredto produce a certificate that they are temperate asregards alcohol. That they should be total abstainersstrikes us as a counsel of perfection impossible to

carry out. The enforcement of sobriety among driversby all possible means would tend to the protection ofthe public and would be possible in some degreein a class which is already compelled to be officiallylicensed. In any case, the prevention of charges ofdrunkenness is of an importance to the public at leastequal to that of the accurate diagnosis of intoxicationin the individual accused.

THE PANEL PRACTITIONER’S RIGHTOF APPEAL.

SOME misunderstanding has arisen regarding the scope of the new rules for appeal under the National Health Insurance Acts which came into force at thebeginning of the year. The amended form of Rules1 to 11 of Order LV B of the Supreme Court, printedin THE LANCET of Jan. 3rd, refers only to appeals fromministerial decisions under Section 89 of the NationalHealth Insurance Act, 1924, on questions relating tothe liability of employed persons to be insured or tothe amount of weekly contributions payable. TheseRules do not in any way affect the important questionof the panel doctor’s right of appeal to the Courtsagainst ministerial decisions affecting him, or the

equally important question of his right to require acase to be stated for the consideration of the High Court.The position on these matters still remains as follows.Against the infliction by the Minister of a pecuniarypenalty there is no right of appeal and no means of Iquestioning the Minister’s decision, provided that the Minister in arriving at his decision has followedthe prescribed procedure. It will be recalled that theMinister’s unrestricted power in this respect was

recently brought into prominence by a case in whichthe Minister inflicted what was very widely regardedas the excessive penalty of £1000. Against any decisiongiven by the Minister in his judicial capacity on anappeal from a decision by an insurance committee,

there is also no right of appeal, neither can an appealbe lodged against what the Department regard as theadministrative act of the Minister in removing a

doctor’s name from the panel. It is true that theprovisions of the Arbitration Act, 1889, are appliedto the hearing or inquiry which precedes the latter twoclasses of ministerial decision, but as regards openingthe doctor’s approach to the Courts the effect of this is-no more than to provide that at any stage of the pro-ceedings the Minister may, or, if directed by the Courtor judge, must state as a special case for the opinion.of the Court any question of law arising in the courseof the proceedings.From the very inception of the National Health

Insurance Act of 1911 the medical profession haveconsidered that the opportunity afforded to the doctorto approach the Courts has been inadequate. Priorto 1913 the view was strongly pressed that the right offinal appeal to the Courts against ministerial decisions

should be widely recognised. Subsequently this viewwas somewhat modified. It was recognised that suchrights could not be unilateral and would have to beextended to insured persons, approved societies, andinsurance committees, with the resultant risks to thedoctor of expense and undesirable publicity; it was.also felt that the Minister, being specially conversantwith the whole subject-matter and alive to the impor-tance of adequate continuity in decisions, might bethe most suitable tribunal for deciding the majorityof cases. There remained, however, the belief thatthere should be some further right of appeal againstthe Minister’s decision to remove a doctor’s name fromthe panel, and the recent case to which reference hasbeen made revived the demand for some check upon.possibly arbitrary or unjust action by the Minister inthe infliction of a pecuniary penalty. The presentview of the central representatives of the medicalprofession on these matters is set out in the draftmemorandum of the evidence to be piaced before theRoyal Commission on National Health Insurance bythe British Medical Association. As may be seen fromthe summary of this memorandum, which we printedlast week, the view is that, while the insurance doctormight justly be made liable to penalty for the wilfulcharging of unauthorised fees and for such generalconduct as is held to be detrimental to the interests ofthe service, and might be subject to serious officialaction for the making of wilfully false statements inconnexion with the records, reports, and certificateswhich he has undertaken to furnish, general questionsof supposed neglect or lack of success or improperbehaviour on the part of the doctor should be solvedby the exercise of the patient’s right to change hisdoctor at any time, just as cases of unreasonableconduct on the part of the patient should normally bedealt with by the doctor’s right to notify that he nolonger desires to be responsible for the case.

If these principles are adopted it is thought thatthe present machinery should not on the whole be-

inappropriate to meet the majority of cases, if twofurther safeguards are provided. These are : (a) in casesof infliction of penalty, an appeal to the Courts shouldbe possible; not only on the ground of improperprocedure, as at present, but also on the ground thatthe penalty inflicted is out of proportion to the offence;(b) in cases of proposed removal from the panel thedoctor should have the right of appeal to a dulyconstituted central professional committee, and thatnot until that committee advises the course should theMinister be able to remove a doctor’s name from the-panel. The General Medical Council would be thenatural tribunal to hear such appeals if to do so camewithin its statutory scope.